Listed below are the requirements broken into two parts to apply for Andrew's Gift assistance. Please complete Part I before proceeding to the application. **Please note** If you have previously applied, you do not need to send additional documentation and proof of an Autism Spectrum Disorder.

PART I

PLEASE READ THE FOLLOWING OUR PRIVACY POLICY, PUBLICITY AND PHOTO RELEASE AND RELEASE AND WAIVER DOCUMENTS BEFORE PROCEEDING TO PART II. PLEASE NOTE THAT INDIVIDUALS ARE ENTITLED TO ONE APPROVED GRANT PER CALENDAR YEAR. ADDITIONALLY, INDIVIDUAL FINANCIAL INFORMATION MAY BE REQUESTED FOR APPROVAL. APPLICANT IS REQUIRED TO SUBMIT DOCUMENTATION FOR PROOF OF AN AUTISM SPECTRUM DISORDER DIAGNOSIS. THE APPLICATION CANNOT BE PROCESSED WITHOUT THIS INFORMATION.

Name of individual who can be contacted regarding details of the grant *

Relationship to Grant Applicant *

Phone number *

Phone number

(###)

###

####

Best days and times to be contacted *

Applicant is required to submit documentation for proof of diagnosis for an Autism Spectrum Disorder. The application cannot be processed without this information. Forward required documentation to one of the following: • Email at andrewsgift26@gmail.com • Fax 813-741-6911 • Mail to P.O. Box 6014, Harrisburg, PA 17112

Description of Goods/Services you are requesting *

This is where you tell us what it is you want to purchase. Provide the following:
• description of goods/services
• name of a service provider and/or vendor along with
• contact information for service provider and/or vendor
***Those applying for summer programs need to submit applications at least 2 months prior to the start of a program
***iPads are gifted 3 times a year at our iPad Days. Those receiving iPads make a commitment to attend an iPad Day and stay the entire day before leaving with the iPad. For those who need to leave early, your iPads will be held for you until the next iPad Day.

Total amount of money requested (If you are requesting an iPad you do not need indicate a price) *

Description of the Grant Applicant *

This is where you describe the person who will receive the goods or services. Tell us about
• their history
• the things they are good at and enjoy the most
• the things that are difficult for self and others around them
• their experiences at school, work & home
If you are requesting goods/services to help support communication/choice please give us detailed information about how the grant applicant currently communicates

Have you sought or are receiving other funding for this request? *

This is where you tell us
• the name of other organizations that you have asked for financial help to get the requested
goods/services
• how much, if any, money they are providing to help pay for the requested goods/services

How will these goods/services benefit the applicant? *

This is where you tell us as specifically as possible
• the goals you hope to accomplish by using these goods/services
• the current concerns that have caused you to seek out funds for goods/services
• how you think these goods/services will be helpful to the applicant

How did you decide to request the specific goods/services? *

This is where you tell us about
• past experiences that tell you that your request will be helpful
• if you are currently working with a professional who will be helping you use the goods/services
• how the goods/services will help to support any long-term goals

Please provide us with any further information or provide any supportive documentation

This is where you provide us with notes of endorsement from professionals who helped you arrive at the decision to request the specific goods/services on this application...send all supportive documentation to any of the following
- Email at andrewsgift26@gmail.com
- Fax 813-741-6911
- Mail to P.O. Box 6014, Harrisburg, PA 17112

***If you are requesting a specialized application (such as ProLoQuo2Go, LAMP Words for Life...) for your iPad, complete the following:

Name of application you are requesting
Name of application developer
Forward a letter of endorsement from a professional who is currently working with the Grant Applicant. Include the name of the professional, credentials & contact information, and a response to the following questions
• What do you want the user of the app to be able to do with this app?
• How is the applicant currently using the application?
• What features of this application are important for this user?
• What other apps were considered?
• Was there a trial use of other apps? If yes, why were they not a good fit?
Send letter of endorsement to any of the following
Email at andrewsgift26@gmail.com
Fax 813-741-6911
Mail to P.O. Box 6014, Harrisburg, PA 17112

I certify that: *

Applicant has read and understands the guidelines of Andrew’s Gift (as outlined on the cover page of this application)

I certify that: *

The information contained in this application is true and accurate to the best of applicant’s knowledge

I certify that: *

Applicant agrees to cooperate with the Board of Directors or the Grant Committee Representative regarding this grant application by providing additional information that may be required, including financial information.

I certify that: *

Applicant understands that the activities funded by the grant may involve hazards to the applicant. Although Andrew’s Gift may fund these activities, Andrew’s Gift does not prescribe, approve or supervise the activities in any way. Applicant expressly and specifically assumes the risk of injury or harm in any activities, and releases Andrew’s Gift from all liability for injury, illness, death, or property damage resulting from the activities

Checking the boxes below signifies agreement with the terms and conditions contained in Part I. *

Publicity and Photo Release

Release and Waiver of Liability

Privacy

I understand that my application cannot be processed until I have submitted proper documentation regarding diagnosis. *

I will submit documentation to Andrew's Gift for proof of an Autism Spectrum Disorder.

I have previously submitted documentation and proof of Autism Spectrum Disorder.

Thank you for applying to Andrew's Gift. If you have not already done so, please submit proof of an ASD diagnosis. The application is incomplete and will not be reviewed until we receive the information. Regards, Dorothy Ward...Andrew's Gift

As part of its application review process, Andrew’s Gift may request additional information from the applicant including financial information.